New Dietary Guidelines Place Added Sugars in the Crosshairs

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JAMA

March 23, 2016

Sugar lovers received some not-so-sweet advice earlier this year.

The 2015-2020 Dietary Guidelines for Americans, produced by the Department of Health and Human Services (HHS) and the Department of Agriculture (USDA), for the first time recommend limiting consumption of added sugars to less than 10% of calories per day (http://1.usa.gov/21N65zL). Previous guidelines only recommended cutting back on calories from such sugars.

The guidelines note that sugar can appear in natural products such as fruits and dairy and as added sugars—those put in foods during preparation or processing or at the dining table. However, they do not limit sugar consumed from natural products because they contain other nutrients needed for healthy diets. The HHS/USDA dietary guideline about added sugars is in line with a March 5, 2015, recommendation from the World Health Organization that also called for restricting added sugar consumption to less than 10% of daily calories (http://bit.ly/1G1H7jn). Neither guideline goes as far as recommendations in a scientific statement from the American Heart Association (AHA) to limit added sugars to no more than 100 calories per day for women and 150 calories per day for men, or about 5% of daily caloric consumption (Johnson RK et al. Circulation. 2009;120[11]:1011-1020).

Lead author of the AHA statement, Rachel K. Johnson, PhD, MPH, RD, professor of nutrition in the University of Vermont’s department of nutrition and food sciences in Burlington, said she was pleased that HHS/USDA specified a calorie limit instead of using vague terms such as “limit intake of added sugars,” seen in previous guidelines. She also emphasized why limiting added sugar consumption is important. “We know that foods high in added sugars, especially sugary drinks, are linked with increased risk of overweight and obesity. Furthermore, added sugars increase the risk of high blood pressure, inflammation, abdominal fatness, and elevated blood lipid levels independent of obesity,” factors associated with cardiovascular disease and type 2 diabetes.

Richard Olson, MD, MPH, of HHS’ Office of Disease Prevention and Health Promotion, whose division led the development of the guidelines, said their data review showed that current intake of added sugars was much higher than ideal based on food-pattern modeling for healthy diets.

“Today in American adults, about 13.4% of their calories come from added sugars, and for children and adolescents, it’s 17%,” Olson said. According to their findings, about 70% of people in the United States consume added sugar above the recommended 10% limit. To help individuals reduce added sugar intake, the guidelines were crafted to give concrete goals instead of just suggestions, he said. “Ten percent is basically a target to move the population down to added sugar amounts that fit in a healthy diet: it’s not a magic number,” he added.

In the typical US diet, 31% of calories from added sugars come from snacks and sweets, and 47% come from added sugars in beverages (not including milk or 100% fruit juices). One-quarter of added sugars come from drinking sweetened soda.

However, despite the fact that sweetened soda is the greatest source of added sugars in the US diet, the guideline authors made no specific recommendations for limiting its consumption, an omission that has garnered criticism.

In a recent forum on cancer and diet, presented in collaboration with the Huffington Post and in association with Harvard Health Publications by the Harvard T. H. Chan School of Public Health in Boston, panel members said a main concern about consuming too much sugar is the association between excess sugar intake and obesity, which is linked to increased cancer risk (https://theforum.sph.harvard.edu/events/cancer-and-diet/). They also noted that small studies suggest sugar intake is linked with a higher risk for certain cancers, independent of obesity.

When panel member Walter Willett, MD, DrPH, chair of the school’s department of nutrition, was asked what 1 policy recommendation he would make to help people change their dietary patterns, he suggested limiting consumption of sugar-sweetened beverages through strategies involving taxation, warning labels, and limiting access.

In an interview, Willett said the guideline authors were deliberately vague when discussing limitation of sugar-sweetened beverages. “[Although] the dietary guidelines are meant to be clear guidelines for the public, they purposely obfuscated to keep them abstract,” Willett said. “Foods and beverages that people should eat are clearly stated, but those to avoid are muddled.”

Marion Nestle, PhD, MPH, professor of nutrition and food studies at New York University in New York City, is also troubled by the lack of clear advice for limiting sugar-sweetened sodas. “Cutting down on sugary drinks is the first thing to do to manage weight problems, so why not say so,” Nestle said in an email exchange. “The 10% of calories recommendation is a huge step forward, but the guidelines don’t explain what it means. One 16-ounce [serving of] Coke or Pepsi pretty much takes care of the entire sugar allotment for the day for most people.”

Don Wright, MD, PhD, HHS’ deputy assistant secretary for health and director of the Office of Disease Prevention and Health Promotion, countered by saying the guideline authors did not want individuals to think a better health option would be to avoid sugary sodas and replace them with other equally sugary beverages such as fruit drinks.

But others advocate for more direct action to reduce sugar-sweetened beverage consumption. In a recent editorial, Johnson highlighted key policy initiatives to reduce such consumption (Johnson RK. Circulation. 2016;133[4]:347-349). The initiatives include public education campaigns; access restriction in schools, child care centers, and workplaces; food packaging labeling; portion size reduction; taxation; and voluntary industry initiatives.

For example, the Healthy, Hunger-Free Kids Act of 2010 and its Smart Snacks in School standards resulted in most schools offering healthier foods to schoolchildren and limiting access to junk food and sugary drinks. Major US restaurant chains, including Applebee’s, Burger King, Chipotle, Dairy Queen, IHOP, McDonald’s, Panera, Subway, and Wendy’s, have also dropped sugary drinks from their kids’ menus.

“Of course, we hope manufacturers will decrease the amount of added sugars in their product,” Johnson added.

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